SC was performed via median laparotomy or laparoscopy with a median mini-laparotomy to exteriorize the colon; a terminal ileostomy was fashioned on a site marked preoperatively by scratching the skin with a small needle; in laparoscopy patients, ileostomy was exteriorized through an adequately widened trocar incision. The rectosigmoidal stump was closed with a linear stapler with or without hand-sewn additional stitches, and placed subcutaneously in left iliac fossa or at the end of the median laparotomy incision. In patients undergoing laparoscopy, this was passed through a trocar incision in left iliac fossa. Skin was always closed over it. At the end of the procedure, two silicone drains were placed in the abdominal cavity, positioning one next to the colonic stump.
If signs of local stump-related sepsis occur during postoperative observation (e.g. fever, swelling and/or tenderness in proximity of the skin covering the tip of the stump, high white blood cells (WBC) count), without signs of abdominal involvement (mute/serous-discharging drains, no abdominal defence, no evidence of collections in the pelvis at ultrasonography or pelvic effusion emanating from the stump at radiography with gastrographyn enema), we use the following approach. A soft, silicone three-way catheter, size Ch. 22-24 is introduced through the anus with the patient in Sims’ position and the balloon is insufflated with 30 ml of saline. Then, the patient is placed in mild Trendelemburg position (approximately 30° from the floor) and rectal washout is started through the afferent channel of the catheter with 1000 ml of saline plus 10 ml of Povidone-Iodine solution (PVI, Betadine®) (1%): this is completed in approximately 2 hours. Finally, slow washout with abundant saline is carried out. During night-time, the catheter is removed and washout is suspended. The procedure is repeated the next day, but PVI is diluted at 0.1%; saline solution is subsequently infused continuously (approximately 8 hours). The washout can be repeated for additional 12 hours.
During the whole procedure it is mandatory to evaluate general health condition and to assess at least daily the serological status (albumin, total protein count, WBC, haemoglobin). Antibiotic is continued until normalization of WBC and remission of fever. The drains are to be kept in place. Most important, the patient should receive enteral nutrition as soon as possible, with high caloric and protein intake. If there is no response within 12 hours, it is safe to remove cutaneous sutures over the stump, opening it when needed draining sepsis through this mucous fistula. Washout can be continued with the opened mucous fistula: we are used to place a drainable 1-piece drainable transparent pouch (Sensura®, Coloplast A/S, Humlebæk, Denmark) connected with a drain bag.